Disclosures. Dexmedetomidine: The Good, The Bad and The Delirious. The Delirious. Objectives. Characteristics of Delirium. Definition of Delirium

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1 Dexmedetomidine: The Good, The Bad and The Delirious Disclosures! I have no actual or potential conflict of interest in relation to this presentation. By John J. Bon, Pharm.D., BCPS Lead Clinical Pharmacist, Critical Care Summa Health System Objectives 1. List two negative consequences associated with the occurrence of delirium. 2. Explain the mechanism of action of dexmedetomidine. 3. Summarize the benefits of dexmedetomidine over other medications commonly used for intensive care unit (ICU) sedation. The Delirious Definition of Delirium Characteristics of Delirium! A common disorder characterized by a recent onset of fluctuating awareness, impairment of memory, attention, and disorganized thinking. Ann Intern Med 2011;154: Intensive Care Med 2008;34: Figure used by permission of E. Wesley Ely, MD, MPH 1

2 Types of Delirium! Hyperactive Increased psycho-motor activity Agitated behavior! Hypoactive Decreased psycho-motor activity Lethargy Often overlooked Incidence of Delirium! Patients age 65 of age 14% to 24% at hospital admission 6% to 56% of non-icu hospital patients 70% to 87% of ICU hospital patients 15% to 53% of postoperative patients Ann Intern Med 2011; 154(11):ITC6-1 ITC-16. Intensive Care Med 2008;34: N Engl J Med 2006;354: Incidence of Delirium! Delirium in ICU patients < 65 years of age By itself, not a statistically significant risk factor! Ouimet and colleagues* Age 64.5 for + delirium vs for no delirium (p = 0.069)! Eli and colleagues t Mean age 54 for + delirium vs. 56 for no delirium (p>0.05) *Intensive Care Med 2007;33: t JAMA 2004;291: Delirium Risk Factors! Advanced age ( 65 years old)! Preexisting dementia! History of stroke! Parkinson disease! Multiple comorbid conditions! Impaired vision or hearing! Male gender! History of alcohol abuse Ann Intern Med 2011; 154(11):ITC6-1 ITC-16. Adverse Consequences of Delirium! Increased ICU Length of stay Lat and colleagues: 12.2 days vs. 7.4 days (p <0.01)*! Increased days on mechanical ventilation Lat and colleagues: 9.1 days vs. 4.9 days (p <0.01)*! Increased overall hospital length of stay Ely and colleagues showed a median of 10 additional days in length of stay t! Care of delirious patients 65 years of age accounts for > 49% of all hospital days. Adverse Consequences of Delirium! Increased number of hospital acquired complications Pressure sores and falls Increased likelihood to be discharged to an long-term care facility! Increased mortality at 6 months and one year post ICU discharge Ely and colleagues showed patients with delirium had a 3x higher risk of 6 month mortality t! Every day of delirium in the ICU associated with a 10% higher mortality risk *Crit Care Med 2009;37: t JAMA 2004;291: Am J Respir Crit Care Med 2009;180: N Eng J Med 2006;354: t JAMA 2004;291: Am J Respir Crit Care Med 2009;180: National Institute for Health and Clinical Excellence (July 2010) [Delirium: diagnosis, prevention and management]. [No. 103]. London. 2

3 Adverse Consequences of Delirium! Delirious ICU patients 18 months post discharge More cognitive problems! Especially names and memory! Non ICU patients also experienced persistent cognitive impairment Memory Social blunders Failed cognitive questionnaire JAMA 2004;291: Crit Care Med 2012;40: Monetary Costs of Delirium! Estimated increased cost of $2,500 to treat a patient with delirium $6.9 billion additional annual Medicare expenditure (2004 dollars)! Daily cost of ICU care $3,500* Additional $1,500 per day of mechanical ventilation Ann Intern Med 2011;154: *Crit Care Med 2005;33: Dexmedetomidine: The Good Unique Mechanism of Action! Benzodiazepines and propofol act on the γ-aminobutyric receptor! Dexmedetomidine is an α 2 -adrenergic receptor agonist Eight times more selective for α 2 -adrenoceptors than clonidine Produces sedation and analgesia! Attributed to α 2A -adrenoceptor subtype Opioid sparing analgesic effect! No apparent effect on respiratory rate or oxygen saturation Drugs 2000;59(2): Drugs 2011;71(11): Dexmedetomidine: FDA Approved Indications! Sedation of initially intubated and mechanically ventilated patients during treatment in an intensive care setting, administered by continuous infusion for up to 24 hours! Sedation of non-intubated patients prior to and/or during surgical and other procedures Incidence of Delirium with Dexmedetomidine vs. Traditional Medications Precedex (dexmedetomidine hydrochloride) prescribing information. Hospira, Inc., Lake Forest, IL USA 3

4 Effect of Sedation With Dexmedetomidine vs. Lorazepam on Acute Brain Dysfunction in Mechanically Ventilated Patients (MENDS Trial)! Double-blind, randomized, controlled study! 106 ICU patients randomized to dexmedetomidine or lorazepam infusion for up to 120 hours! Target RASS determined by patient s care team! Dexmedetomidine infusion rate Initial: 0.15 mcg/kg/hr, titratable to 1.5 mcg/kg/hr! Lorazepam infusion rate Initial:1mg/hr, titratable to 10mg/hr! Both arms: Intermittent or continuous infusion fentanyl JAMA 2007;298(22): MENDS Trial Results! More days alive without delirium or coma Dexmedetomidine median 7 days vs. lorazepam 3 days (p=0.01)! Less prevalence of coma Dexmedetomidine 63% vs. lorazepam 92% (p<0.001)! More time within 1 point of desired RASS score Dexmedetomidine 80% vs. lorazepam 67% (p=.04) JAMA 2007;298(22): Dexmedetomidine vs. Midazolam for Sedation of the Critically ILL Patient (SEDCOM Trial)! Prospective, double-blind, randomized trial conducted in 68 facilities in five countries! Randomized 2:1 to receive Dexmedetomidine (n=250) over midazolam (n=125)! Target Richmond Agitation and Sedation Score (RASS) of -2 to +1! Dexmedetomidine initiated at 0.8 mcg/kg/hr Optional 1 mcg/kg loading dose! Midazolam initiated at 0.06 mg/kg/hr Optional 0.05 mg/kg loading dose! Both arms : prn iv fentanyl and iv haloperidol JAMA 2009;301(5): SEDCOM Trial Results! No difference in target RASS score! Significant difference in delirium Dexmedetomidine 54% vs. midazolam 76.6% (p<0.001)! Shorter median time to extubation Dexmedetomidine 3.7 days vs. midazolam 5.6 days (p=0.01)! Increased incidence of bradycardia Dexmedetomidine 42.2% vs. midazolam 18.9% (p<0.001)! Nonsignificant increase in those requiring treatment (p=0.07)! Significantly less tachycardia (p<0.001) and less hypertension requiring treatment (p=0.02) JAMA 2009;301(5): Cost Savings Dexmedetomidine vs. Midazolam for Long-term ICU Sedation! Secondary analysis of SEDCOM study data Decreased total patient ICU cost in dexmedetomidine patients! $9679 median cost savings over midazolam (95% CI, to 2314, p=0.01)! Cost savings Reduced ICU length of stay! Median savings $6584 Reduced mechanical ventilation! Median savings $2958 Dexmedetomidine and the Reduction of Postoperative Delirium after Cardiac Surgery! 118 elective cardiac valve surgery patients! Prospective, open-label, randomized trial Three arms! Dexmedetomidine n= mcg/kg bolus 0.2 to 0.7 mcg/kg/hr infusion! Propofol n=38 25 to 50 mcg/kg/min infusion! Midazolam n=40 Crit Care Med 2010;38: Psychosomatics 2009;50:

5 Dexmedetomidine and the Reduction of Postoperative Delirium after Cardiac Surgery! Incidence of delirium Dexmedetomidine 3% Propofol 50% p<0.001 Midazolam 50%! Delirious patients Significantly longer ICU stay (4.1 days vs. 1.9 days, p<0.001) Significantly longer hospital LOS (10 days vs. 7.1 days, p<0.001) Psychosomatics 2009;50: Safety of Dexmedetomidine Use Beyond 24 Hours! MENDS Trial Dexmedetomidine infused for up to 5 days Similar side adverse events! Except bradycardia (HR < 60) Nine dexmedetomidine arm vs. two lorazepam arm (p=0.03)! SEDCOM Study Dexmedetomidine infused for a median of 3.5 days (range 2 days to 5.2 days) Similar adverse events! Except bradycardia (HR< 40) Nonsignificant increase in those requiring treatment (p=0.07) Am J Health-Syst Pharm 2010;67: Safety of Dexmedetomidine Use Beyond 24 Hours! Guinter and Kristeller Reviewed 6 adult studies with > 24hrs of dexmedetomidine use Conclusion! Safety and efficacy of dexmedetomidine in adults likely persists for beyond 24 hours, without the emergence of rebound effects after discontinuation. Safety of Dexmedetomidine Use Beyond 24 Hours! Wagner and Brummett Little risk of rebound phenomena occurring following prolonged infusions Am J Health-Syst Pharm 2010;67: Seminars in Anesthesia, Perioperative Medicine and Pain 2006;25: Safety of Dexmedetomidine Use Beyond 24 Hours! Kunisawa* Dexmedetomidine is approved in Japan for a duration up to five days No restrictions on long term use in Brazil, Columbia and the Dominican Republic! Venn and colleagues t Dexmedetomidine well tolerated for up to seven days! Roukonen and colleagues** Dexmedetomidine infusion! Median of 40 hours (range hours) Thank You! *Therapeutics and Clinical Risk Management 2011;7: t Intensive Care Med 2003;29: **Intensive Care Med 2009;35:

6 Question 1! Delirium is associated with? A. Decreased length of hospital stay B. Decreased mortality C. Long-term cognitive impairment D. Decreased ventilator free days E. a and b Question 2! Dexmedetomidine s mechanism of action is most similar to? A. Morphine B. Diazepam C. Propofol D. Clonidine! Answer: C! Answer: D Question 3! Dexmedetomidine for sedation tends to? A. Decrease the amount of supplemental narcotics required B. Increase the amount of supplemental benzodiazepines required C. Increase delirium D. Induce coma E. b and c! Answer: A Question 4! Dexmedetomidine use for ICU sedation is associated with? A. An increased incidence of delirium B. Elevated serum triglycerides C. Decreased incidence of delirium D. Respiratory depression E. c and d! Answer: C Question 5! Studies have shown rebound hypertension from abrupt cessation of dexmedetomidine. A. True B. False! Answer: B Dexmedetomidine: the Good, the Bad, + the Delirious Simon Lam, PharmD, BCPS Cleveland Clinic Medical ICU Clinical Specialist 36 6

7 ObjecEves Evaluate the clinical data comparing the use of dexmedetomidine (DEX) with other sedaeves Dexmedetomidine Use Ideal PaEent Wrong PaEent Discuss the poteneal role of DEX for ICU sedaeon in selected paeents Everyone else Dexmedetomidine MOA Dexmedetomidine vs. Haloperidol Randomized, open- label pilot trial Enrolled paeents in whom extubaeon was not possible solely due to agitaeon Dexmedetomidine mcg/kg/hr vs. haloperidol mg/hr Primary outcome: Eme to extubaeon 39 Reade et al. Crit Care 2009;13:R75 40 DEX vs. Haloperidol Baseline characteris.cs DEX (n=10) Haloperidol (n=10) p APACHE II 13.3 (10-18) 15.5 (11-19) Time intubated prior to randomizaeon, h 45.0 ( ) 65.2 ( ) Outcome DEX (n=10) Haloperidol (n=10) p Time to extubaeon, h 19.9 (7.3-24) 42.5 ( ) ICU length of stay, d 1.5 (1-3) 6.5 (4-9) Longer QTc*, % Data in median (IQR), unless otherwise noted *One paeent had excessive QTc prolongaeon necessitaeng haloperidol disconenuaeon DEX vs. Propofol/Midazolam Pilot randomized trial of dexmedetomidine versus standard care (propofol or midazolam) StraEfied for baseline sedaeve, sedaeon target (RASS 0 to - 3 or RASS - 4 to - 5) and admission type DEX up to 1.4 mcg/kg/hr vs. propofol up to 4 mg/ kg/hr (67 mcg/kg/min) or midazolam Daily sedaeon stops included in study protocol Co- primary outcomes Time at target sedaeon (non- inferiority) Length of ICU stay Reade et al. Crit Care 2009;13:R75 41 Ruokonen et al. Intensive Care Med 2009;35:

8 DEX vs. Propofol/Midazolam Outcome DEX (n=41) Propofol/ Midazolam (n=44) Time at target sedaeon, % 64 (0-99) 63 (0-100) ns RASS target 0 to - 3, % 74 (0-99) 64 (9-100) ns RASS target - 4 to - 5, % 42 (4-64) 62 (0-85) DuraEon of mechanical venelaeon, h 77.2 ( ) ( ) p 0.109* Delirium incidence, % PosiEve CAM- ICU assessments, n% Data presented as median (range) unless otherwise indicated *p=0.025 afer adjustment for baseline straeficaeon on mulevariate analysis ns Dexmedetomidine Use Ideal paeent Wrong paeent Everyone else AgitaEon precludes weaning Require heavy sedaeon; hypotension, bradycardia Ruokonen et al. Intensive Care Med 2009;35: Debate QuesEon Should DEX be rou.nely used over other medica.ons as the sedaeve of choice for criecally ill paeents? DEX Superiority? Associated with better clinical outcomes / surrogate markers! Favorable safety profile! DEX superiority! Patients already receiving best-care! DEX vs. Lorazepam: Clinical Outcomes Outcome DEX (n=52) Lorazepam (n=51) p value Mechanical venelaeon- free days, d 22 (0-24) 18 (0-23) 0.22 ICU LOS, d 7.5(5-19) 9 (6-15) day mortality, n (%) 9 (17) 14 (27) 0.18 Data in median (IQR), unless otherwise noted DEX vs. Midazolam: Clinical Outcomes Riker R et al. JAMA 2009; 301: (SEDCOM) Outcome DEX (n=244) Midazolam (n=122) p value Time to extubaeon, d 3.7 ( ) 5.6 ( ) 0.01 ICU LOS, d 5.9 ( ) 7.6 ( ) day mortality, n(%) 55 (22.5) 31 (25.4) 0.60 Jakob SM et al. JAMA 2012; 307: (MIDEX) Outcome DEX (n=249) Midazolam (n=251) p value Pandharipande P et al. JAMA 2007; 298: (MENDS) 47 DuraEon of mechanical venelaeon, h 123 (67-337) 164 (92-380) 0.03 ICU LOS, h 211 ( ) 243 ( ) day mortality, n(%) 68 (27.3) 53 (21.1) NS Data in median (IQR), unless otherwise noted 48 8

9 DEX vs. Lorazepam: Surrogate Outcomes DEX vs. Midazolam: Surrogate Outcomes SEDCOM Delirium prevalence: 54% vs. 76%; p<0.001 MIDEX NeurocogniEve AE: 29% vs. 27%; p=0.689 AgitaEon Anxiety Delirium DEX Midazolam Pandharipande P et al. JAMA 2007; 298: Riker R et al. JAMA 2009; 301: Jakob SM et al. JAMA 2012; 307: Benzodiazepines and Delirium Dex vs. BZD: Outcomes MedicaEon Delirium OR p value Lorazepam 1.2 ( ) Midazolam 1.7 ( ) 0.09 Fentanyl 1.2 ( ) 0.09 Morphine 1.1 ( ) 0.24 Propofol 1.2 ( ) 0.18 Likely earlier extubaeon with DEX No other significant clinical outcome differences Likely less delirium Methodological issues with MENDS Inconsistent effect with midazolam BZDs known to be associated with delirium Treatment of delirium may not be associated with clinical outcomes Pandharipande P et al. Anesthesiology 2006; 104: Use of SedaEves in US DEX vs. Propofol: Outcomes Clinical Outcome DEX (n=249) Propofol (n=247) p value Time to extubaeon, h 69 (39-184) 93 (45-286) 0.04 DuraEon of mechanical venelaeon, h 97 (45-257) 118 (48-327) 0.24 ICU LOS, h 164 (90-480) 185 (93-520) day mortality, n(%) 43 (17.3) 48 (19.4) NS Surrogate Outcome DEX (n=249) Propofol (n=247) p value NeurocogniEve AE, n(%) Delirium, n(%) CAM- ICU posieve (48h post sedaeon), n(%) Data in median (IQR), unless otherwise noted 45 (18.3) 7 (2.8) 71 (28.7) 17 (6.9) NA 22 (9.6) 31 (13.7) Wunsch H et al. Crit Care Med 2009; 37: Jakob SM et al. JAMA 2012; 307: (PRODEX) 54 9

10 Safety Profile Best PracEce SedaEon Strategies Hypotension MENDS SEDCOM MIDEX* PRODEX Bradycardia MENDS* SEDCOM* MIDEX* PRODEX DEX Control DEX Control * p<0.05 * p<0.05 Jakob SM et al. JAMA 2012; 307: ; Riker R et al. JAMA 2009; 301: ; Pandharipande P et al. JAMA 2007; 298: Analgo- sedaeon Early MobilizaEon Daily Awakening SedaEon Strategies Spontaneous Breathing Trial TitraEon Protocol Brook AD CCM 1999; 27: ; Kress JP. NEJM 2000; 342:1471-7; Girard TD. Lancet 2008; 371: Strom T. Lancet 2010; 375: ; Schweickert. Lancet 2009; 373: SedaEon Strategies: Clinical Outcome TitraEon Protocol Daily Awakening Daily Awakening with Spontaneous Breathing Analgo- sedaeon Early MobilizaEon 62h earlier extubaeon 2.2d decrease ICU LOS 5.9d decrease hospital LOS 50% reduceon tracheostomy 2.4d decrease MV 3.5d decrease ICU LOS 66% decrease CT- brain and MRI 3.1d decrease MV 3.8d decrease ICU LOS 4.3d decrease hospital LOS 14% ARR in mortality at 1 year 4.2d decrease MV 9.7d decrease in ICU LOS 24d decrease in hospital LOS 10% ARR in declining funceonal status at discharge 2.4d decrease in MV 2.0d decrease in ICU LOS Brook AD CCM 1999; 27: ; Kress JP. NEJM 2000; 342:1471-7; Girard TD. Lancet 2008; 371: Strom T. Lancet 2010; 375: ; Schweickert. Lancet 2009; 373: Dexmedetomidine: the Good, the Bad, + the Delirious Simon Lam, PharmD, BCPS Cleveland Clinic Medical ICU Clinical Specialist 58 QuesEon 1 When compared to midazolam, dexmedetomidine is more effeceve at maintaining paeents within their target sedaeon goals. A. True B. False Answer: B QuesEon 2 ICU paeents sedated with dexmedetomidine have a shorter duraeon of mechanical venelaeon when compared to propofol. A. True B. False Answer: B

11 QuesEon 3 Compared to sedaeon with benzodiazepines, dexmedetomidine use has been associated with all of the following except? A. Decrease delirium B. Decrease incidence of bradycardia C. Increase Eme at target sedaeon goals D. Increase ability to achieve deep sedaeon Answer: B 61 11

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